Tidbits for YOUR Pearly Whites

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In carpentry, the first rule every beginner is taught is: MEASURE TWICE, CUT ONCE! Similarly, dentistry requires the same attention to detail. If one follows my preceding three dental “Commandments“, the prognosis for their teeth can be pretty solid long-term.

For most dental patients, I recommend that they have needed dental work accomplished in as few steps as possible–Do it once; do it the right way the first time in order to avoid multiple procedures. For example, if a tooth needs a crown (Commandment #3), then I may be able to patch it with a filling, but will have to treat the tooth again in the future to protect it with a crown. Treating a tooth twice means twice the risk of injury to the nerve in the root canal of the tooth–since every time a tooth is damaged, infected or restored (“filled”), the nerve inside the tooth is injured/inflamed and must heal. That can happen only so many times before the tooth is irreparably damaged and gives up the ghost–leading to extraction.

I advise my patients that the amount of dental care they need will be directly proportional to the amount of dental work they needed (or should have had…) while in their teenage years. Every 20 years or so, they will need to have the dental work updated or replaced–just like those “20-year” shingles on a roof. Now, I can hear all the nay-sayers out there saying, “Ha! Well my dentist did a great job–my fillings have been there for almost 30 years.” To that, I say, “Please refer back to previously discussed Commandment #1 and Commandment #2, because nothing lasts forever and to maximize long-term predictability of dental care, one must be preemptive in its maintenance.

Figure 2–Before photos (2006)

Though the patched roof in Fig. 1 may not match or look as good as the original (it may be part of a long-term replacement plan by the owner), it should function well until the rest of the project can be completed. For the patient in Fig. 2 and 3, I created a phased treatment plan so that all the procedures needed for his extreme dental makeover (and thus the expenses!) were accomplished over a 7 year period to permit numerous travel opportunities for him and his wife and necessary delays to allow for orthodontic therapy, sinus augmentation and implant healing time. The important part was that he completed his goals on HIS time schedule; got the cosmetic and functional result he desired and each tooth was only restored once!

Fig. 3 Smile complete (2012)

The only time that a “phased” approach to care doesn’t make sense is when one or more teeth must be touched multiple times unnecessarily. It’s not a mandate, but merely advice to avoid increasing the risk of complications. Remember: Commandment #4 really means that the more times a tooth is touched, the more likely one is to lose the tooth! So, if you are in need of extensive dental care, ask your dentist if the option of a phased approach to care would be best for you. If your dentist cannot answer that question to your satisfaction, give my office a call and schedule a consultation appointment to discuss your needs–I’ll do my best to provide sound advice.

Either way: Do it once; do it the right way–the first time.

Until next time–Keep Smiling! Please check in again, or visit my website at:

Most of us learned in school that things expand and contract when exposed to changes in temperature. Bridge builders knew long ago that if they didn’t allow for it, a bridge would fall into the chasm when temperatures plummet in winter! Conversely, the bridge would buckle when exposed to the heat of summer. That’s why they have expansion joints–the familiar “cha-chunk, cha-chunk” when you drive your car on and off of a bridge.

Dentists have had to deal with this problem for years. Unfortunately, our patients don’t abide by the seasons! They expose their teeth to extremes of heat (coffee, soup, tea) and cold (ice cream, ice water, high-speed snow skiing!!) all the time. Have you ever been to a nice restaurant where the doting waiter offers you ice cream AND coffee for dessert?!? (Pity your poor teeth with those old silver fillings!) In fact, after ice and popcorn kernels, the most common cause of tooth fracture in my office over the years comes after Thanksgiving–“But, Doc, I was only eating mashed potatoes when it broke!” Of course, they were homemade–full of chunky, “hot-spots” that caused excessive expansion that broke off an already weakened piece of tooth.

Even more insidious is the contraction to cold. When the metal filling contracts, a microscopic gap opens to allow for fluids, bacteria and sugars to enter. The scary part is that this “leakage” is the reason that silver fillings work in the first place! The leakage of fluids permits oxidation (“rust”) that “seals” the natural space between the tooth and the silver filling. The end result, however, is recurrent tooth decay that weakens the tooth and/or leads to infection of the root canal–which is why even small fillings don’t last forever.

I advise patients that my “cut-off” for determination whether a tooth should be crowned or “just have a filling” is my 50% Rule:

When the volume of the filling exceeds 50% of the available, remaining healthy tooth structure, the tooth should be restored with a crown to minimize the risk of cracking the tooth when heat, chewing or clenching forces are applied.

These old silver amalgam fillings are accidents waiting to happen!

Of course, it is only a guideline. And, it doesn’t mean that treatment can’t be staged over time–it just increases the risk of fracture “while you wait.” I will usually offer my best “estimate of longevity” when a patient asks me, “How long can I wait?” But in my heart, I know my response should call to mind an age-old problem:

My crystal ball is broken, let’s use yours! 😉

If only life were that easy…

Until next time–Keep Smiling! Please check in again, or visit my website at:

The band, KANSAS, crooned: “Nothing lasts forever but the Earth and Sky.” As much as my patients wish otherwise, everything in dentistry (except extractions, of course!) has a finite lifespan, too. One can assume that the useful life of a typical filling will average somewhere between 10 – 15 years; it’s a “Bell Curve” like we all remember from the test grades in high school. Some may not make the average; some may stay in the tooth longer, but all will eventually develop recurrent decay due to leakage and/or break the tooth under the forces of clenching/chewing combined with the oxidation (“rust”) of the material. Materials that do not corrode will always last longest. The smaller the filling, the longer it lasts–and vice-versa.

Fig. 1. But the shingles are still there!

My patients know that I L-O-V-E! analogies. I seem to have one for almost every condition that presents in my office. Material breakdown/failure is a favorite topic. Everyone has seen an old barn like the one in Fig. 1 at some time in their lives. The shingles are still there, but the barn is destroyed underneath it–the shingles quit doing their job many years earlier!

Dental work is no different.

Fig. 2. This is NOT going to end well! Better to have patched that “little” hole before the structure is destroyed.

The dentist can identify and repair/restore small issues before they become big ones (see Fig. 2). Most patients don’t realize that the fillings that your parents had your dentist place for you as a teen (or you had done in your early adult years) were not meant to last forever, but rather, to “get you through” until the teeth are lost to gum disease, fracture, or extensive decay, or until you can afford to upgrade them to more permanent restorations that Mom and Dad won’t have to pay for…

Fig. 3: Attention and meticulous maintenance will result in long-lasting health, function and beauty in dentistry, too!

With a little luck and good health, you WILL outlive your dental work. So, to make the most of it, one must do the things that we consistently NAG our patients about: Floss and brush the teeth every night; cut out the excess sugar and acidic food and drink in the diet; see the dentist twice a year and abide by the 5 Commandments of Dentistry that are being discussed in my blog!

Until next time–Keep Smiling! Please check in again, or visit my website at:

As the old proverb guides us: no one plans to fail–they just fail to plan.

In that vein, my goal is to provide my patients with a treatment plan for high quality dentistry based upon estimates of longevity–for both the patient and the restorative material. Bottom line: if one wants to keep one’s teeth, treatment must be completed BEFORE it hurts and BEFORE the tooth breaks–that is, BEFORE there is any symptomatic reason to do so. The reality is that, sometimes, even modern dental techniques can’t save a fractured, infected tooth.

The alternative to this rule is to relinquish the personal control and timing of preemptive care and subject oneself to the rigors of rescue dentistry (to be discussed in Rule of Thumb #4) after the tooth/teeth become symptomatic. Rescue Dentistry is the “bread and butter” of the General Dentist–because the need for treatment is now obvious to the skeptical patient and “required” for the relief of pain and/or suffering. For the dentist, the dreaded “sales pitch” is now unnecessary–there is nothing more to prevent or preempt; for the patient, there is now a complete loss of control over the ability to plan and the freedom of choice; for the tooth, it may be too late; and for the wallet, whether there are remaining dental benefits or not, is a moot point. I like to refer to these teeth as: Christmas Eve Teeth–I think the reason should be reasonably self-explanatory.

Figure 1: Silver amalgam weakens teeth and oxidizes with time, changing the physical and chemical properties of the material..

Though it can be effective, rescue therapy is less predictable, more extensive, more expensive and much shorter-lived. The most complicated treatments that my patients need are a direct result of the long-term reliance upon short-term dental treatments based on silver/mercury amalgam fillings or tooth-colored plastic fillings and sealants.

For reasons I cannot fully fathom, many new patients to my practice are under the impression that once a tooth is filled, it’s “done”. Nothing could be further from the truth. My favorite analogy goes like this:

Why do we change the oil in our cars every 3-4000 miles? We could just wait and replace the engine every 15000 miles when the engine seizes and save two or three trips to Jiffy Lube!

Figure 2: Even bonding isn’t perfect! Bonding cannot be relied upon to resist the forces generated between the jaws. Fillings merely replace the parts of the tooth destroyed by tooth decay.

Fillings work pretty much the same way. If one waits too long to update or upgrade a filling, the tooth will “seize” (see Figure 1 and 2) by fracture or root canal abscess. Rather than wait for the bitter end of a filling’s life, it would be preferable and more predictable to replace it when the first signs of deterioration are evident.

Dentists are routinely taught that we should educate our patients about the benefits of “preventive dentistry.” But the longer I do this, the more I see that preventive dental work fail because of personal habits, dietary challenges, systemic health issues and just plain wear and tear. I prefer to think of myself as a “Preemptive Dentist.” If one wants dental work to last, one needs to consider the length of time it is expected to do so–the patient’s life expectancy! Patients must also be forewarned that dental benefits are never going to cover 100% of the cost. The average plan supports and pays for the “least expensive alternative treatment”, usually referring to a less expensive option that will last for a 5-7 year period–the average amount of time an American spends in any one place of employment. (If you think about it, when the tooth “seizes” the patient is conveniently working somewhere else and likely subject to the restrictions and limitations of a different benefit company.)

Figure 3: “Christmas Eve teeth” with old silver fillings that have cracked the teeth

The tooth in figure 1 above was identified 6 months earlier as old and potentially weak. Figure 2 shows a fractured tooth with a moderately sized tooth-colored, bonded composite filling. The patient with the teeth in figure 3 had been advised to have them crowned 4 years earlier due to the deterioration and age of the fillings (both more than 20 years old). The molar (larger tooth on the right side of figure 3) was completely split down the middle–the patient delayed treatment because THERE WAS NO PAIN, NO SYMPTOMS. When the patient finally “caved” to my recommendations (“badgering” in his words!) and agreed to update his dental work, the molar needed to be removed because the crack (and bacteria) had extended into the root canal and split the root.

Cost is often cited as a barrier. Six months beforehand, the tooth in the figure 1 above could have had a new filling (~$250), or a crown ($1200-1500). Now that the tooth is fractured and painful, the restorability of the tooth is in question and the rescue therapy to correct it will cost ~$3500 (including gum surgery, root canal therapy AND build-up and crown). The out-of-pocket cost will be roughly $2500, or 10 TIMES the total cost of the new filling with no benefits. If the tooth cannot be saved, the tooth can be removed and replaced with an implant: ~$5000.

After 25 years in practice– I have concluded that there are 5 simple guidelines that a patient needs to consider when confronted with the need for dental treatment. These guidelines apply across generations, across socio-economic statuses, across all the races, creeds and political strata!

My Five Commandments, or rather, my “5 Rules of Thumb” are as follows:

Five Commandments of Modern Dentistry

Be preemptive. “Yankee Mentality” serves no one well when it comes to your teeth!